Optimizing bone marrow harvesting sites for enhanced mesenchymal stem cell yield and efficacy in knee osteoarthritis treatment

Table 3 Merits and de-merits of bone marrow from various anatomical locations

Anatomical site	Merits	Demerits
Anterior superior iliac spine	Ease of access: Superficially located and easy to palpate, facilitating quicker and less invasive procedures	Lower cell purity: Increased risk of blood dilution due to fatty tissue, potentially reducing MSC concentration
	Adequate yield: Provides a good volume of aspirate with acceptable TNC and CFU-f yields	Variable CFU-f yield: Typically lower CFU-f counts compared to the posterior superior iliac spine, which may affect the therapeutic potential of the aspirate
	Lower complication rate: Reduced risk of neurovascular injury and other complications when performed with proper technique	Patient discomfort: Proximity to muscle attachments can cause discomfort during and after the procedure
	High culture success rate: High success rate in MSC culture, indicating reliable cell viability and expansion potential	Postoperative pain: Potential for significant postoperative pain and hematoma formation
Posterior superior iliac spine	High cell yield: Provides a high concentration of TNCs and CFU-fs, making it the preferred site for harvesting high-quality aspirates	Increased technical difficulty: Less accessible, particularly in patients with high BMI or anatomical variations, requiring more complex positioning and technique
	Reduced blood dilution: Lower fatty infiltration results in higher cell purity and reduced blood contamination	Higher risk of complications: Proximity to the sacroiliac joint and gluteal neurovascular bundle increases the risk of neurovascular injury
	Consistency in results: Yields consistent results with less variability in cell counts across different patients	Patient discomfort: A deeper location and the need to traverse more tissue can cause significant post-procedural pain
	Gold standard for MSC yield: Considered the gold standard for bone marrow harvesting due to its high MSC yield and well-established protocols	Donor-site morbidity: Associated with significant morbidity, including pain, hematoma, and nerve injury, which may deter its use in certain populations
Proximal tibia	Convenience in certain surgeries: Proximity to the knee joint makes it convenient during knee-related surgeries, reducing procedure time	Lower MSC concentration: Typically provides a lower concentration of MSCs compared to the iliac crest, which may limit its effectiveness in regenerative therapies
	Adequate cell yield in some cases: Can produce a reasonable volume of aspirate, especially when large volumes are needed	Greater variability in yield: High variability in cell yield depending on factors such as patient age, BMI, and bone density, leading to inconsistent results
	Reduced risk of major complications: Stable site with a lower risk of major complications like neurovascular injury, making it a safer choice in some contexts	Difficulty in aspiration technique: Requires careful technique to avoid complications such as cortical bone fracture, particularly in osteoporotic patients
	Integrated into knee surgeries: Easily integrated into knee surgeries like TKA, adding minimal additional risk and reducing invasiveness	Lower culture success rate: MSC culture success rate is lower compared to the iliac crest, which may limit its utility in certain therapeutic applications
Proximal humerus	Convenience in shoulder surgeries: Located within the surgical field during shoulder procedures, reducing the need for an additional surgical site	Limited data: While promising, there is limited data compared to the iliac crest, and long-term outcomes need further study
	High MSC yield: Can yield a comparable number of progenitor cells to the iliac crest, making it a viable alternative for bone marrow aspirate concentrate preparation	Variability with age: Potential variability in MSC yield with age, although studies suggest this site may still be reliable across different age groups
	Reduced morbidity: Less invasive compared to iliac crest harvesting, with a lower risk of complications and patient discomfort	Not standard practice: Not as widely used or studied as the iliac crest, leading to less familiarity and potentially greater variability in outcomes
Distal femur	Ease of access during knee surgeries: Easily accessible during knee surgeries such as TKA, reducing the need for additional procedures	Lower MSC concentration: Significantly lower MSC concentration compared to the iliac crest, potentially limiting its effectiveness in high-demand applications
	Lower postoperative complications: Reduced invasiveness with potentially fewer postoperative complications, particularly in patients with previous pelvic surgeries	Lower culture success rate: The culture success rate for MSCs is lower than that of the iliac crest, which may affect the feasibility of its use in large-scale therapeutic applications
	Potential for integration into existing surgeries: Can be seamlessly integrated into existing knee procedures, adding minimal risk and enhancing therapeutic options	Inconsistent yield: Variability in cell yield can lead to inconsistent outcomes, which may affect the reliability of the site for routine use in MSC harvesting
Acetabulum	Dual-purpose during hip surgeries: Accessible during hip surgeries, allowing simultaneous bone marrow harvesting without additional surgical risks	Limited to hip procedures: Primarily applicable in the context of hip surgeries, limiting its broader use in other orthopedic applications such as knee OA
	Comparable yield to iliac crest: Studies suggest a comparable progenitor cell yield to the iliac crest, making it a feasible alternative in certain contexts	Not a primary choice for knee OA: While effective for hip procedures, its role in knee OA treatment is more indirect and not commonly pursued as a first choice

BMI: Body mass index; CFU: Clone forming unit; MSC: Mesenchymal stem cell; OA: Osteoarthritis; TKA: Total knee arthroplasty; TNC: Total nucleated cell count.